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Medicare 101: Your Guide to Understanding Coverage and Enrollment
Taking the first steps toward learning about Medicare plans can be overwhelming—there are many terms to understand and options to consider, so it’s completely understandable if the handbooks and pamphlets have left you dazed and confused. The good news is that we’re here to help you cut through the clutter of Medicare plans.In just minutes, we can compare Medicare Advantage plan options that may be available to you.
What is Medicare, and who is eligible?
Medicare refers to the federal health insurance program available to eligible individuals over 65 or with certain disabilities. It is composed of Part A (hospital insurance), Part B (medical insurance), Part D (Prescription Drug plans), and optional Part C (Medicare Advantage) or Medicare Supplement (Medigap) plans. It was created in 1965 for people ages 65 and over, regardless of income, medical history, or health status. In 1972, the program expanded to cover those under age 65 with certain health conditions.
Original Medicare is administered by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS). Like Social Security, Original Medicare is an entitlement program, with most U.S. citizens aged 65 and older eligible to receive Medicare Part A (hospital insurance). Individuals and their spouses qualify if they are eligible for Social Security payments and will not have to pay a premium for Part A if they paid payroll taxes for a certain amount of time, typically at least 10 years. If you didn’t work long enough to be entitled to Original Medicare benefits, you still may be eligible to enroll, but you may be subject to additional costs.
Most people become eligible for Medicare three months before their 65th birthday; however, individuals with certain disabilities or medical conditions may qualify sooner.
People Turning 65: Generally, eligibility for Medicare begins when an individual turns 65 years old. The Initial Enrollment Period (IEP) is a seven-month period that starts three months before the month you turn 65, includes your 65th birthday month, and ends three months after your birthday month.
People Receiving Social Security Disability Insurance (SSDI) Payments: People under the age of 65 who receive Social Security Disability Insurance (SSDI) payments generally become eligible for Original Medicare after a two-year waiting period.
People with End-Stage Renal Disease (ESRD): People with ESRD become eligible for Original Medicare with no waiting period. Coverage typically begins on the first day of the fourth month of a course of regular dialysis treatments, but may start earlier if you begin home dialysis training or receive a kidney transplant.
People with Amyotrophic Lateral Sclerosis (ALS): People with ALS are eligible for Medicare as soon as they start receiving Social Security Disability Insurance (SSDI) benefits. The standard two-year waiting period and the five-month waiting period for SSDI benefits are waived for people with ALS.
The Four Parts of Medicare Insurance
The Medicare program has four different parts. Original Medicare consists of Medicare Part A and Part B, while Medicare Part C plans are offered through private companies approved by the program. Medicare Part D offers coverage for prescription drugs.
Original Medicare (Parts A and B)
Original Medicare is made up of Part A (hospital insurance) and Part B (medical insurance). Many physicians accept Original Medicare, but not all, so you need to confirm this when you make an appointment with your doctor. People who choose Original Medicare may also want to add Part D (prescription drug coverage) to round out their Medicare coverage needs. It is important to understand that Part B of Original Medicare only pays for about 80% of all healthcare costs, so it’s important to consider options to cover the gap.
> Learn More About Original Medicare
Medicare Prescription Drug Plans (Part D)
Medicare Part D is a stand-alone drug plan offered through private insurers that will cover most of your outpatient prescription medications. Keep in mind that if you choose a Medicare Advantage plan instead of Original Medicare, the benefits of Part D may be incorporated into your Medicare Advantage plan.
Medicare Advantage (Part C)
Medicare Part C plans are approved by the Medicare program and sold through private insurers. These plans are known as Medicare Advantage plans and must legally offer the same benefits as Original Medicare, but may include additional potential routine benefits. The costs and coverage from Medicare Advantage plans will vary depending on the private insurer you purchase from.
Using Medicare Supplement Insurance (Medigap)
Because Part B of Original Medicare only covers about 80% of healthcare costs, beneficiaries may choose to enroll in a Medicare Supplement Insurance plan (Medigap) to help cover the remaining costs, like coinsurance, copayments, and deductibles.
In most states, there are currently eight Medicare Supplement Insurance plans available through private insurers. Each plan—which is standardized across all the states offering it—has a letter designation: A through N. Keep in mind that not all supplement plans are offered by every private insurer, and private insurers set their own premium rates, so it’s important to shop around.
The Medicare Initial Enrollment Period Checklist
You can enroll in Original Medicare during the Initial Enrollment Period (IEP), which begins three months before and ends three months after your 65th birthday. Individuals on Social Security Disability Insurance (SSDI) become eligible for Original Medicare in the 25th month of SSDI benefits and are automatically enrolled in the program by Social Security. Some people may be eligible for Special Enrollment Periods based on their employment history or other health insurance coverage they have.
Turning 65 soon? Our Initial Enrollment Period checklist can help you understand enrollment timelines, eligibility, and how to sign up.
If You Miss Your Enrollment Window
General Enrollment Period, which runs from January 1 to March 31. People who sign up during the General Enrollment Period will be eligible for coverage the following July. Late enrollment penalties typically apply to people who miss their Initial Enrollment Period. Depending on the Medicare plan you apply for, these penalties can vary from 10% for every 12 months you delay enrollment to 1% per month.
If You’re Taking Social Security
If you’re on Social Security (which you can begin at age 62), then you should be automatically enrolled in Medicare Part A and/or Part B when you turn 65. However, you should check to confirm that this is true—either by contacting Social Security or the Medicare program—or you may incur a late enrollment penalty.
If You’re Still Working at 65
Once you turn 65, Medicare is considered your primary insurer, making other insurance companies your secondary. This is true even if you haven’t applied for Original Medicare yet. It’s also true even if you have retiree health insurance, individual health insurance, or COBRA. It’s important to understand how Original Medicare coverage works if you’re still employed because it means you might not be able to count on your other forms of insurance to pay for your hospital or doctor’s office bills once you turn 65.
If You’re a High-Earner
If you choose Original Medicare and your income is above a certain threshold, you’ll pay more for Parts B and D. Premiums for both parts can come with a surcharge when your adjusted gross income (plus tax-exempt interest) is more than:
$109,000 if you are single
$218,000 if married and filing jointly
In 2026, high earners pay $284.10 to $689 per month for Part B, depending on income level, and they also pay extra for Part D coverage, from $14.50 to $91 on top of the regular premiums.
If You and Your Spouse are Both Eligible
Original Medicare is an individual benefit, so each member of your family needs to apply for Original Medicare separately. There are no family Medicare plans.
If You Might Need Long-Term Care
Those new to Original Medicare (and even some who’ve been enrolled for a while) are sometimes surprised to learn that Original Medicare generally does not cover long-term care. However, there are certain circumstances where services related to long-term care may be covered. One example is services needed after a hospitalization from an acute-care event. In this case, Original Medicare will pay for medically necessary skilled nursing facility (SNF) or home health care. However, “custodial care” services that help you with the activities of daily living, like dressing and bathing, are not covered.
If You Need to Appeal a Medicare Coverage Decision
There may be an occasion when you don’t agree with an Original Medicare health plan decision about your coverage or payment. In this case, you’re entitled to file an appeal. There are five levels to the appeals process, some of which are settled at lower levels and others taking more time. Be sure to present as much relevant information as you can when you first make your appeal—your physician can help. It’s also important to collect any relevant hospital records or information from other providers and/or suppliers. In situations where a decision needs immediate attention, you can request a fast-track decision, which must be made within 72 hours. However, this requires the agreement of your doctor and/or your Medicare plan.
How can I better understand my Medicare plan options?
We specialize in helping consumers understand the ins and outs of Medicare plans. We can help you understand the possible benefits that may be available to you. In just minutes, we can compare Medicare Advantage plan options that may be available in your area. It’s free, and there’s no obligation to enroll.
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